Application to register for the

F-111 SHOAMP Health Care Scheme
Group 1 participants
The information provided in this form will be used to determine your eligibility for assistance
under the F-111 Study of Health Outcomes in Aircraft Maintenance Personnel (SHOAMP)
Health Care Scheme.
Important information
D9203 - 03/14 - P1 of 4
The following personnel are eligible for treatment and counselling as a Group 1 participant: Who is eligible?
Privacy notice
Giving false or misleading information is a serious offence.
For information, please call F-111 Health Care from
anywhere in Australia on:
How to contact DVA
1800 728 007
This claim must be lodged with the Department of Veterans’ Affairs. Please refer to page 4,
Section G for information.
Please use a black or blue pen to complete this form.
Note: You must first submit a claim for an F-111 Tier classification before completing this form. F-111
Tier classification provides recognition of the level of your involvement in F-111 deseal/reseal and
fuel tank maintenance work (see section A).
Information is also available on the F-111 website: http://f111.dva.gov.au
Where to lodge this claim
Your personal information is protected by law, including the Privacy Act 1988. Your
personal information may be collected by the Department of Veterans’ Affairs (DVA) for
the delivery of government programs for war veterans, members of the Australian Defence
Force, members of the Australian Federal Police and their dependants.
Read more: How DVA manages personal information
• Personnel involved in the F-111 deseal/reseal training conducted in Sacramento,
USA;
• Personnel, including supervisors, involved in the formal F-111 deseal/reseal
programs;
• Personnel involved in the regular burning or disposal of F-111 deseal/reseal
products;
• Personnel involved in ad hoc ‘pick and patch’ fuel tank maintenance on F-111
aircraft prior to January 2000;
• Personnel involved in other maintenance or directly related tasks prior to
January 2000 where their work required physical entry to an F-111 fuel tank to
conduct that maintenance or task;
• Personnel who dismantled and/or disposed of the canvas from the Air Transportable
Deseal/Reseal Hangar (the ‘Rag Hangar’);
• Personnel whose primary place of duty was within the deseal/reseal hangars or
the Air Transportable Deseal/Reseal Hangar (the ‘Rag Hangar’) at RAAF Base
Amberley during one or more of the formal deseal/reseal programs;
• Personnel employed in Engine Test Cell No 1 during the period 1976–86;
• Fuel farm workers and personnel involved in the transport, delivery and handling
of F-111 deseal/reseal products including SR51/51A. These workers and personnel
must have regularly performed duties of supply and disposal of F-111 deseal/reseal
products;
• Personnel immersed in the Warrill Creek Settling Pond at RAAF Base Amberley; and
• Work Experience students at Hawker de Havilland who worked inside the tanks.
The following personnel are eligible for counselling as a Group 2 participant:
• The immediate family members of Group 1 participants; and
• Service personnel and civilian employees who are not covered by the Group 1 definition
but were employed at RAAF Base Amberley during the F-111 deseal/reseal programs
(the 1st and 2nd deseal/reseal programs 1977-82 and 1991-93; the spray seal
program 1996-99; and the wings deseal/reseal program 1985-92).
SECTION B
Participant’s Details
3 Surname
4 Given name(s)
6 Date of birth
8 Street Address
10 Telephone numbers
1 Have you applied for a Tier
classification?
12 What is your current status?
SECTION A Tier Classification details
5 Sex
7 Service number (if applicable)
9 Postal Address
(if different from above)
Home Work/Mobile
2 What was the decision regarding
your Tier classification?
D9203 - 03/14 - P2 of 4
11 E-mail address
POSTCODE
( )
No
Yes
Current ADF member
Ex-ADF member
Civilian
Male Female
POSTCODE
You must have your Tier classification determined before submitting
this form. Complete form D9021 at http://f111.dva.gov.au
Go to question 2
Granted Tier 1 classification
Granted Tier 2 classification
Granted Tier 3 classification
No Tier classification recognised,
Group 1 eligibility determined
No Tier classification recognised,
Group 1 eligibility rejected
You are not eligible for SHOAMP Health
Care Scheme Group 1 Status.
Please complete the SHOAMP Health
Care Scheme Group 2 form (D9204) if
you think you may meet the Group 2
definition.
SECTION C Compensation claim details
13 Do you wish to receive medical
treatment through the SHOAMP
Health Care Scheme?
14 Please provide your bank account
details for reimbursement of
medical expenses that you may
be entitled to via Electronic
Funds Transfer (EFT)
15 Do you wish to participate in
the Better Health Program?
D9203 - 03/14 - P3 of 4
SECTION D Bank account details for reimbursements
-
SECTION E Better Health Program
The Better Health Program provides eligible participants with access to cancer screening for colorectal cancer and
melanoma and disease prevention information on erectile dysfunction, depression and anxiety. If you are assessed as a
Group 1 participant or have been granted Tier classification, you are eligible to participate in the Better Health Program.
No
Yes
You are able to receive access to counselling and other health programs
through VVCS - Veterans and Veterans Families Counselling Service.
Go to Section E.
To receive medical treatment under the SHOAMP Health Care Scheme, you
must submit a claim for compensation. Contact the relevant compensation
authority for the appropriate form:
• Department of Veterans’ Affairs: 133 254,
http://www.dva.gov.au/clientforms, Form D2020 - Claim for Rehabilitation
and Compensation
• WorkCover Queensland: 1300 362 128,
http://www.workcoverqld.com.au OR
• Comcare: 1300 366 979,
http://www.comcare.gov.au
Please list the condition(s) for which you have claimed compensation:
Name of Account (must be in your name or joint name)
Branch (BSB) number
Account number
Name of bank, credit union or building society
Branch location
No
Yes
DVA will write to you to provide information on the Better
Health Program.
Go to Section F
(If insufficient space, attach a separate sheet)
D9203 - 03/14 - P4 of 4
16 Do you have a partner or
child/ren who wish to apply for
the SHOAMP Health Care
Scheme?
• I declare that the details provided in this form are complete and correct.
• I am aware that there are penalties for making false statements or giving misleading information.
• I consent to the release of medical, clinical and other information to the Department of Veterans’ Affairs by all medical
practitioners, hospitals, clinics, insurance companies, Centrelink, the Department of Defence or other organisations, in
relation to this claim or its review.
You must sign this form yourself if you can – even if someone else has filled it in for you. If someone else signs on your behalf
they must provide a document that proves their authority to sign on your behalf.
/ /
Signature
Please send completed form to:
F-111 SHOAMP Health Care Scheme
GPO Box 9998
Brisbane, QLD, 4001
Before returning this form please check the following

SECTION F Group 2 application form for partners and children
SECTION G Declarations and consent
Have you signed the declaration above and checked this form carefully?
Have you filled in all the parts that apply to you?
If your application is approved and you are assessed as a Group 1 participant, your partner and child/ren will be
eligible to apply as a Group 2 participant of the SHOAMP Health Care Scheme. Group 2 participants can receive
access to counselling sessions through the VVCS - Veterans and Veterans Families Counselling Service.
No
Yes We will send out Group 2
application forms to your
address
Go to Section G
If you require help filling in this form, please call F-111 Health Care on 1800 728 007 during business hours.
Number of forms required:
Have you attached any additional supporting/required documentation?

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